TWA 800 Recommendations Focus On
Improving Wiring Safety
By Sean Broderick
23-Aug-2000
6:25 PM U.S. EDT
Recommendations approved today by the U.S. National Transportation Safety
Board (NTSB) put a strong emphasis on improving the way everyone in
commercial aviation - from aircraft designers to mechanics - deals with
wiring systems.
Two of the four recommendations, made as part of the TWA 800
investigation final draft report, deal specifically with wiring design,
safety, and upkeep. The NTSB called on the U.S. Federal Aviation
Administration (FAA) to review aircraft design specifications to determine
what wiring systems are safety-critical. Once that's done, standards on how
to protect the most critical wire systems should be established and put into
place.
The board also wants the FAA to come up with new continued airworthiness
guidelines for handling wiring systems, including a way to record in-service
wiring problems, new training for mechanics on how to recognize and deal
with degrading wiring, and improving inspection procedures by using new
technology.
A third recommendation calls on the FAA to review manufacturer design
practices on bonding components in fuel tanks with an eye on eliminating
ignition sources, while a fourth urges the agency to come up with ways to
eliminate silver sulfide build-ups from fuel tank components.
As expected, the board pegged an explosion in the center fuel tank as the
cause of the July 17, 1996 crash of the TWA Boeing 747-131 that killed all
230 onboard. Contributing factors cited were the notion that fuel tank
explosions could be prevented solely by eliminating ignition sources, and
Boeing's design that place air conditioning packs under the 747 center fuel
tank without either insulation to prevent heat build-up in the tank or a way
to remove oxygen from the tank.
Investigators could not determine "with certainty" what ignited the fuel,
but the board believes the "most likely scenario" was a short-circuit
originating outside the center tank that was transferred to lower-voltage
center wing tank fuel quantity indication system (FQIS) wiring. The FQIS
wiring is designed with a voltage level that, by itself, would not pose an
ignition threat.
Failing to nail down the ignition source hardly makes the four-year, $35
million probe a failure, however. In fact, several people involved in the
investigation say that forcing investigators to examine all potential
ignition scenarios is what brought myriad other safety deficiencies, such as
the extent of wiring problems, to light.
"If we would have found the ignition source in the third week, think of
all the discoveries we might not have made," former NTSB Vice Chairman
Robert Francis, who was the top board member at the on-site part of the TWA
probe, told AviationNow.com . "The work that's been done over the last four
years has been a tremendous benefit to civil aviation safety worldwide,
going well beyond fuel tank safety."
Board member John Goglia echoes Francis' theme, calling for the industry
"to not let this work go away, to not forget the lessons learned. We must
continue with the diligence to make sure every single item investigators
have identified is brought to a satisfactory conclusion."
Goglia, a long-time airline mechanic before joining the board, believes
the TWA 800 accident probe findings will leave a memorable mark in aviation
safety history. "It's the Aloha for non-structural systems," he told
AviationNow.com , referring to the 1988 Aloha 737 incident that opened the
industry's eyes to the seriousness of aging aircraft structural problems.
The board approved 25 findings as part of the TWA report. Key ones
include determining that silver sulfide build-ups commonly found inside
tanks pose an ignition risk, designs that put heat-generating equipment
directly under fuel tanks without proper insulation or fuel inerting can
"unnecessarily increase the amount of time" that aircraft operate with a
deadly fuel/air mixture, and "until recently, insufficient attention has
been paid to the condition of aircraft electrical wiring," resulting in
potential safety hazards.
The board did not pull back any previous recommendations. During
testimony, board and staff members stressed the importance of ensuring the
FAA follows through with still-unresolved recommendations, including
developing fuel inerting systems.
Before this week's board meeting, NTSB had issued 11 recommendations
based on information gleaned from the TWA 800 probe. Only one of them
remains classified as open/unacceptable: a request to require temperature
probes in fuel tanks so pilots can monitor fuel temperatures. FAA says
pending programs such as tank ventilation and inerting systems would
eliminate the need for the temperature probes, but the board wants to see
the programs put into practice before accepting the agency's response to the
recommendation.
The two-day meeting ended with the board unanimously approving the
probable-cause statement, the findings, and the recommendations. A final
report, which will likely change little from the working document that was
the centerpiece of discussion this week, will be out later this year.